VSRA MEMBERSHIP

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The Victoria Stroke Recovery Association (VSRA) provides weekly communication and adaptive physical exercise programs for stroke survivors and a support group for care partners. The weekly program also includes a social component which includes music enrichment, educational, creative and social activities. In addition, we incorporate into the program monthly Stroke Survivor and Care Partner Support Groups led by a Counsellor.

The VSRA Program is designed for Stroke Survivors and their Care Partners and we would like to respectfully highlight that in order to participate, members should be:

independently mobile (with or without aids such as canes, walkers, wheelchairs or scooters)
able to eat independently
able to attend to personal hygiene and toileting
able to organize themselves to safely arrive and leave all VSRA sessions (walking, biking, driving, bussing, being driven by a care partner or HandyDart)

Members wishing to participate in the program who are not able to independently do these activities are very welcome to attend but must be accompanied by a care partner who can provide the needed assistance.

The annual membership fee is $50. All applications will be reviewed and approved by the VSRA Board. The decision of the Board regarding each application will be conveyed to the applicant.

Privacy

The Victoria Stroke Recovery Association protects the privacy of individual members. The personal information obtained in this application form may be used only in the administration of programs offered by VSRA.

Membership Application Form

"*" indicates required fields

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This field is for validation purposes and should be left unchanged.

Membership Type*

Stroke Survivor ($50)

Care Partner ($50)

New or Renewing?*

New Membership

Membership Renewal

Method of Payment

Cheque

Cash

e-transfer

Contact Information

Name*

First Last

Address*

Street Address City Province Postal Code

Phone (Home)

Phone (Cell)

Email*

Date of Birth

DD slash MM slash YYYY

Year of Stroke

How did you hear about us?*

Emergency Contact

Name

First Last

Relationship

Phone (Home)

Phone (Cell)

Personal and Medical Information

Name of Family Physician

Phone

Do you have any health concerns our program should be aware of? Please describe below.

Do you have diabetes?

Yes

If yes, what type?

Type 1

Type 2

Do you wear glasses?

Yes

Do you wear hearing aids?

Yes

Do you have difficulty swallowing?

Yes

Do you have allergies? (food, medication, environmental)

Yes

If yes, please list

Do you carry an Epipen?

Yes

Special Diet - Please check all that apply

Diabetic

Thickened Fluids

Gluten free

Dairy free

Vegetarian

Vegan

Other

If other, please specify

Mobility - Please select all that apply

Cane

Walker

Mobility Scooter

Wheelchair

Transport - Please select all that apply

Drive (or have someone drive you)

Take public transportation

HandyDart

Bike

Walk

Communication

Please select which applies.

Talking

No difficulty

Some difficulty

A lot of difficulty

Understanding

No difficulty

Some difficulty

A lot of difficulty

Reading

No difficulty

Some difficulty

A lot of difficulty

Writing

No difficulty

Some difficulty

A lot of difficulty

What helps you communicate? Please select all that apply.

Keywords

Communication device

Speak slowly / quietly

Pointing / gestures

Writing / drawing

iPad or tablet

Extra time

Choices

Communication book

Camera

Pictures / maps

Family / friends

Member Waiver of Liability

The Victoria Stroke Recovery Association is dedicated to ensuring the health and safety of all members in our program. There are some potential risks involved in program activities. This document is necessary to ensure you understand the activities of the program and the responsibilities/expectations of members. Please read through this document carefully.

Physical Activity

I understand the program may include physical activity and participate at my own risk.

I understand that the Victoria Stroke Recovery Association has taken steps to reduce the risk of injury from physical activity.

I am physically fit enough to participate in the program.

If I am no longer physically fit enough to participate, I will stop.

Waiver Acknowledgement*

By checking this box I acknowledge that I have read, understood and agree with the above statements.

By typing my name in this field, I acknowledge:

I am participating in the program with knowledge of the risks explained above.

I accept the risks explained above.

Participation in the program is voluntary.

I can withdraw from the program at any time.

The Victoria Stroke Recovery Association is not responsible for any injury, illness, disability, death, or property damage that happens when:

I participate in the program

I am on the program site or after I leave the site.

Directory Consent*

The VSRA prints a member directory each year so that members can contact each other outside of group time. By consenting, you permit the VSRA Member Directory to contain your name, suburb, telephone number (cell and/or home), and email address.

Yes, I consent to be listed in the Directory.

No, I do not wish to be listed.

Confidentiality Agreement*

I agree not to disclose any personal information about a group member, including names, physical descriptions, biological information, or specific interactions, to anyone outside the group. This information is considered personal and private.

Consent to Share Stories, Photos, and Videos*

I give permission for the Victoria Stroke Recovery Association (VSRA) to use my name, photo, video, or work for educational and promotional purposes. This may include use in newsletters, brochures, resource guides, presentations at workshops or conferences, on the VSRA website and social media (e.g., Facebook), and in fundraising or training materials. I understand that these materials will be used positively to promote stroke recovery support, and that I can withdraw or change my consent at any time.

Yes, I consent to the use of my media/stories.

No, I do not consent.

Victoria Stroke Recovery Association (VSRA) Code of Conduct
As a member of the Victoria Stroke Recovery Association, I will:
1. Abide by the values of the Victoria Stroke Recovery Association, which are respect, inclusion, and support.
2. Bring honour and dignity to Victoria Stroke Recovery Association and uphold the reputation and integrity of the organization.
3. Demonstrate respect for all members through words, actions and behaviour.
4. Be vigilant in ensuring an environment that is safe and protects members from the threat of emotional, physical, verbal or sexual abuse.
5. Uphold and protect the personal and professional reputation of other members.
6. Respect other members’ rights to privacy and the confidentiality of members’ personal information.
7. Act with honesty and integrity when dealing with property, monies and any other assets belonging to the Victoria Stroke Recovery Association.
8. Pursue at all times the aims of the Association.
9. Not speak on behalf of the organization, unless it is either expressly indicated in a job description, upon invitation, or with authorization from the Board.
10. Respect and uphold the anti-discrimination laws of Canada and British Columbia. The Victoria Stroke Recovery Association will not tolerate discrimination against a member or non-member of the Association based on race, national or ethnic origin, citizenship, colour, religion, sex, age, mental or physical ability, political beliefs, socio-economic status, health related status, sexual orientation, or marital status.
11. Respect and abide by the laws of British Columbia and Canada.

I will uphold this code of conduct. I will fulfill my role and responsibility in service to the Victoria Stroke Recovery Association, and only act within the limitations of my personal authority in the discharge of my duties.

Name of Member

First Last

Name of Representative, if applicable

First Last

Relationship of Representative to Member

Date Submitted

DD slash MM slash YYYY

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